Pneumonia in a child

Pneumonia in a child is an acute infectious disease of predominantly bacterial origin, characterized by focal lesions of the respiratory parts of the lungs, respiratory disorders and intra-alveolar exudation, as well as infiltrative changes on chest radiographs. The presence of radiographic signs of pulmonary parenchyma infiltration is the "gold standard" for diagnosing pneumonia, allowing it to be distinguished from bronchitis and bronchiolitis.

ICD-10 code

• J12 Viral pneumonia, not elsewhere classified.
• J13 Pneumonia due to Streptococcus pneumoniae.
• J14 Pneumonia caused by Haemophilus influenzae.
• J15 Bacterial pneumonia, not elsewhere classified.
• J16 Pneumonia due to other infectious organisms, not elsewhere classified.
• J17 Pneumonia in diseases classified elsewhere.
• J18 Pneumonia, unspecified.

Epidemiology of pneumonia in children

Pneumonia is diagnosed in approximately 15-20 cases per 1000 children in the first year of life, approximately 36-40 cases per 1000 children of preschool age, and in school and adolescence, the diagnosis of "pneumonia" is established in approximately 7-10 cases per 1000 children and adolescents.

The incidence of hospital pneumonia depends on the contingent and age of patients (it accounts for up to 27% of all nosocomial infections), it is highest in young children, especially newborns and premature babies, as well as in children who have undergone surgery, trauma, burns, etc.

Mortality from pneumonia (including influenza) averages 13.1 per 100,000 population. Moreover, the highest mortality is observed in the first 4 years of life (it reaches 30.4 per 100,000 population), the lowest (0.8 per 100,000 population) is observed at the age of 10-14 years.

Mortality from hospital-acquired pneumonia, according to the National Nosocomial Infection Surveillance System of the USA, at the turn of the last and current centuries was 33-37%. In the Russian Federation, mortality from hospital-acquired pneumonia in children during this period has not been studied.

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Causes of pneumonia in children

The most common pathogens of community-acquired pneumonia are Streptococcus pneumoniae (20-60%), Mycoplasma pneumoniae (5-50%), Chlamydia pneumoniae (5-15%), Chlamydia trachomatis (3-10%),

Haemophilus influenzae (3-10%), Enterobacteriaceae (Klebsiella pneumoniae, Escherichia coli, etc. - 3-10%), Staphylococcus aureus (3-10%), Streptococcus pyogenes, Chlamydia psittaci, Coxiella bumeti, etc. However, it is necessary to take into account that the etiology of pneumonia in children and adolescents is very closely related to age.

In the first 6 months of a child's life, the etiologic role of pneumococcus and Haemophilus influenzae is insignificant, since antibodies to these pathogens are transmitted from the mother in utero. The leading role at this age is played by E. coli, K. pneumoniae and S. aureus. The etiologic significance of each of them does not exceed 10-15%, but they are the ones that cause the most severe forms of the disease, complicated by the development of infectious toxic shock and lung destruction. Another group of pneumonias at this age is pneumonia caused by atypical pathogens, mainly C. trachomatis, which children become infected with from their mothers intranatally, rarely in the first days of life. Infection with P. carinii is also possible, which is especially significant for premature babies.

Starting from 6 months and up to 6-7 years, pneumonia is mainly caused by S. pneumoniae (60%). Often, acapsular Haemophilus influenzae is also isolated. H. influenzae type b is detected less frequently (7-10%), it usually causes severe pneumonia complicated by lung destruction and pleurisy.

Pneumonia caused by S. aureus and S. pyogenis is detected in 2-3% of cases, usually as complications of severe viral infections such as influenza, chickenpox, measles and herpes. Pneumonia caused by atypical pathogens in children of this age is mainly caused by M. pneumoniae and C. pneumoniae. It should be noted that the role of M. pneumoniae has clearly increased in recent years. Mycoplasma infection is mainly diagnosed in the second or third year of life, and C. pneumoniae infection is diagnosed in children over 5 years of age.

In children of this age group, viruses can be both an independent cause of the disease and a participant in viral-bacterial associations. The respiratory syncytial (RS) virus is of the greatest importance, occurring in approximately half of cases of viral and viral-bacterial origin. In a quarter of cases, the etiological factor is parainfluenza viruses types 1 and 3. Influenza viruses A and B and adenoviruses play a minor role. Rhinoviruses, enteroviruses, and coronaviruses are rarely detected. Pneumonia caused by measles, rubella, and chickenpox viruses has also been described. As already mentioned, in addition to its independent etiological significance, respiratory viral infection in young and preschool children is an almost obligatory background for the development of bacterial inflammation.

The causes of pneumonia in children over 7 years of age and adolescents are practically no different from those in adults. Most often, pneumonia is caused by S. pneumoniae (35-40%) and M. pneumoniae (23-44%), less often by C. pneumoniae (10-17%). H. influenzae type b, and pathogens such as Enterobacteriaceae (K. pneumoniae, E. coli, etc.) and S. aureus are practically not encountered.

Pneumonia in patients with immunodeficiency deserves special mention. In children with primary cellular immunodeficiencies, in HIV-infected patients and AIDS patients, pneumonia is most often caused by Pneumocysticus carinii and Candida fungi, as well as M. avium-intracellare and cytomegalovirus. In humoral immunodeficiency, S. pneumoniae is most often isolated, as well as staphylococci and enterobacteria, and in neutropenia, gram-negative enterobacteria and fungi.

Causes of community-acquired pneumonia in patients with immunodeficiency

Patient groups	Pathogens
Patients with primary cellular immunodeficiency	Pneumocystis Candida fungi
Patients with primary humoral immunodeficiency	Pneumococci Staphylococci Enterobacteria
Patients with acquired immunodeficiency (HIV-infected, AIDS patients)	Pneumocystis Cytomegaloviruses Mycobacterium tuberculosis Candida fungi
Patients with neutropenia	Gram-negative enterobacteria Fungi of the genus Candida, Aspergillus, Fusarium

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Pathogenesis of pneumonia in children

Among the features of the pathogenesis of pneumonia in young children, the most important is the low level of anti-infective protection. In addition, it is possible to note the relative insufficiency of mucociliary clearance, especially in respiratory viral infections, with which, as a rule, pneumonia in a child begins. The tendency to edema of the mucous membrane of the respiratory tract and the formation of viscous sputum also contributes to the disruption of mucociliary clearance.

There are four known main causes of pneumonia:

• aspiration of oropharyngeal secretions;
• inhalation of an aerosol containing microorganisms;
• hematogenous spread of microorganisms from an extrapulmonary source of infection;
• direct spread of infection from adjacent affected organs.

In children, microaspiration of oropharyngeal secretions is of greatest importance. Aspiration of large amounts of upper respiratory tract and/or stomach contents is typical for newborns and infants. Less common is aspiration during feeding and/or vomiting and regurgitation. In young and preschool-aged children, airway obstruction is of greatest importance, especially in the case of broncho-obstructive syndrome.

Factors predisposing to aspiration/microaspiration

• Encephalopathy of various origins (post-hypoxic, with brain malformations and hereditary diseases, convulsive syndrome).
• Dysphagia (vomiting and regurgitation syndrome, esophageal-tracheal fistulas, achalasia of the cardia, gastroesophageal reflux).
• Broncho-obstructive syndrome in respiratory, including viral, infections.
• Mechanical violations of protective barriers (nasogastric tube, tracheal intubation, tracheostomy, esophagogastroduodenoscopy).
• Repeated vomiting with intestinal paresis, severe infectious and somatic diseases.

What causes pneumonia?

Symptoms of pneumonia in children

Classic symptoms of pneumonia in children are non-specific - shortness of breath, cough (with or without sputum), fever, weakness, and symptoms of intoxication. Pneumonia should be suspected if a child develops cough and/or shortness of breath, especially in combination with fever. Corresponding percussion and auscultatory changes in the lungs, namely shortening of the percussion sound, weakening or, conversely, the appearance of bronchial breathing, crepitation or fine bubbling rales are determined only in 50-77% of cases. It should be remembered that in early childhood, especially in children in the first months of life, these manifestations are typical of almost any acute respiratory infection, and physical changes in the lungs with pneumonia in most cases (with the exception of lobar pneumonia) are practically indistinguishable from changes in bronchitis.

Symptoms of hospital (nosocomial) pneumonia in children

According to WHO, the symptoms of pneumonia in children are characterized by the following signs:

• a feverish condition with a body temperature above 38 °C for 3 days or more;
• shortness of breath (with a respiratory rate of more than 60 per minute for children under 3 months, more than 50 per minute for children under 1 year, more than 40 per minute for children under 5 years);
• retraction of the compliant areas of the chest.

Classification

Pneumonia in children is usually divided depending on the conditions of its occurrence into community-acquired (home) and hospital-acquired (hospital, nosocomial). The exception is pneumonia in newborns, which is divided into congenital and acquired (postnatal). Postnatal pneumonia, in turn, can also be community-acquired and hospital-acquired.

Community-acquired pneumonia (CAP) is a disease that develops in the normal conditions of a child's life. Hospital-acquired pneumonia (HAP) is a disease that develops after a child's three-day stay in a hospital or during the first three days after discharge.

It is customary to consider ventilator-associated hospital pneumonia (VAHP) and ventilator-non-associated hospital pneumonia (VnAHP). There are early VAHP, developing in the first 3 days of artificial ventilation (ALV), and late VAHP, developing starting from the 4th day of ALV.

Pneumonia may affect an entire lobe of the lung (lobar pneumonia), one or more segments (segmental or polysegmental pneumonia), alveoli or groups of alveoli (focal pneumonia), adjacent to the bronchi (bronchopneumonia), or involve the interstitial tissue (interstitial pneumonia). These differences are revealed mainly by physical and radiographic examination.

Based on the severity of the disease, the degree of damage to the lung parenchyma, the presence of intoxication and complications, mild and severe, uncomplicated and complicated pneumonia are distinguished.

Complications of pneumonia include infectious toxic shock with the development of multiple organ failure, destruction of the lung parenchyma (bullae, abscesses), involvement of the pleura in the infectious process with the development of pleurisy, empyema or pneumothorax, mediastinitis, etc.

Types of pneumonia

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Complications of pneumonia in children

[ 14 ], [ 15 ], [ 16 ], [ 17 ]

Intrapulmonary destruction

Intrapulmonary destructions are suppuration with the formation of bullae or abscesses at the site of cellular infiltration in the lungs, caused by some serotypes of pneumococcus, staphylococci, H. influenzae type b, hemolytic streptococcus, Klebsiella, and Pseudomonas aeruginosa. Pulmonary suppurations are accompanied by fever and neutrophilic leukocytosis until emptying, which occurs either into the bronchus, accompanied by increased cough, or into the pleural cavity, causing pyopneumothorax.

Synpneumonic pleurisy

Synpneumonic pleurisy can be caused by any bacteria and viruses, from pneumococcus to mycoplasma and adenovirus. Purulent exudate is characterized by low pH (7.0-7.3), cytosis above 5000 leukocytes in 1 μl. In addition, the exudate can be fibrinous-purulent or hemorrhagic. With adequate antibacterial therapy, the exudate loses its purulent nature and pleurisy gradually resolves. However, complete recovery occurs in 3-4 weeks.

Metapneumonic pleurisy

Metapneumonic pleurisy usually develops at the stage of resolution of pneumococcal, less often - hemophilic pneumonia. The main role in its development belongs to immunological processes, in particular the formation of immune complexes in the pleural cavity against the background of the disintegration of microbial cells.

As already mentioned, metapneumonic pleurisy develops at the stage of pneumonia resolution after 1-2 days of normal or subnormal temperature. The body temperature rises again to 39.5-40.0 °C, and the general condition is impaired. The febrile period lasts an average of 7 days, and antibacterial therapy has no effect on it. Radiologically, pleurisy with fibrin flakes is detected; in some children, echocardiography reveals pericarditis. In the peripheral blood analysis, the number of leukocytes is normal or decreased, and the ESR is increased to 50-60 mm/h. Fibrin resorption occurs slowly, over 6-8 weeks, due to the low fibrinolytic activity of the blood.

Pyopneumothorax

Pyopneumothorax develops as a result of an abscess or bulla breaking through into the pleural cavity. There is an increase in the amount of air in the pleural cavity and, as a result, a shift in the mediastinum.

Pyopneumothorax usually develops unexpectedly: pain syndrome, respiratory failure up to respiratory failure occur acutely. In case of tense valve pyopneumothorax, urgent decompression is indicated.

Symptoms of pneumonia

Diagnosis of pneumonia in children

During physical examination, special attention is paid to identifying the following signs:

• shortening (dullness) of the percussion sound over the affected area of the lung;
• local bronchial breathing, sonorous fine bubbling rales or inspiratory crepitations during auscultation;
• increased bronchophony and vocal fremitus in older children.

In most cases, the severity of these symptoms depends on many factors, including the severity of the disease, the prevalence of the process, the age of the child, the presence of concomitant diseases. It is important to remember that physical symptoms and cough may be absent in approximately 15-20% of patients.

A peripheral blood test should be performed in all patients with suspected pneumonia. A white blood cell count of about 10-12x10 ⁹ /l indicates a high probability of bacterial infection. Leukopenia less than 3x10 ⁹ /l or leukocytosis greater than 25x10 ⁹ /l are unfavorable prognostic signs.

Chest X-ray is the main diagnostic method for pneumonia. The main diagnostic sign is inflammatory infiltrate. In addition, the following criteria are assessed, which indicate the severity of the disease and help in choosing antibacterial therapy:

• pulmonary infiltration and its prevalence;
• presence or absence of pleural effusion;
• the presence or absence of destruction of the lung parenchyma.

Repeated radiography allows us to assess the dynamics of the process against the background of the treatment being carried out and the completeness of recovery.

Thus, the clinical and radiological criteria for the diagnosis of community-acquired pneumonia are considered to be the presence of changes in the lungs of an infiltrative nature, revealed by chest radiography, in combination with at least two of the following clinical signs:

• acute febrile onset of the disease (T>38.0 °C);
• cough;
• auscultatory signs of pneumonia;
• leukocytosis > 10x10 ⁹ /l and/or band shift > 10%. It is important to remember that a clinical and radiological diagnosis cannot be equated with an etiological diagnosis!

A biochemical blood test is a standard method of examining children with severe pneumonia who require hospitalization. The activity of liver enzymes, the level of creatinine and urea, and electrolytes in the blood are determined. In addition, the acid-base balance of the blood is determined. In young children, pulse oximetry is performed.

Blood cultures are performed only in severe pneumonia and, if possible, before the use of antibiotics in order to establish an etiologic diagnosis.

Microbiological examination of sputum in pediatrics is not widely used due to technical difficulties in collecting sputum from children under 7-10 years of age. It is carried out mainly during bronchoscopy. The material for the study is coughed up sputum, aspirates from the nasopharynx, tracheostomy and endotracheal tube, and cultures of pleural puncture.

Serological methods of research are also used to determine the etiology of the disease. An increase in the titers of specific antibodies in paired sera taken during the acute period and during the recovery period may indicate mycoplasma, chlamydia or legionella infection. This method, however, does not affect the treatment tactics and has only epidemiological significance.

Computer tomography has a 2-fold higher sensitivity in detecting foci of infiltration in the lower and upper lobes of the lungs. It is used in differential diagnostics.

Fibrobronchoscopy and other invasive techniques are used to obtain material for microbiological examination in patients with severe immune disorders and for differential diagnostics.

[ 18 ], [ 19 ], [ 20 ]

Differential diagnosis

The differential diagnosis of pneumonia in children is closely related to the child’s age, as it is determined by the characteristics of pulmonary pathology in different age periods.

In infancy, the need for differential diagnostics arises in diseases that are difficult to treat with standard treatment. In these cases, it should be remembered that, firstly, pneumonia can complicate another pathology, and secondly, clinical manifestations of respiratory failure can be caused by other conditions:

• aspiration;
• foreign body in the bronchi;
• previously undiagnosed tracheoesophageal fistula, gastroesophageal reflux;
• malformations of the lungs (lobar emphysema, coloboma), heart and large vessels;
• cystic fibrosis and aganistrypsin deficiency.

In children aged 2-3 years and older, the following should be excluded:

• Kartagener's syndrome;
• pulmonary hemosiderosis;
• nonspecific alveolitis;
• selective immunodeficiency IgA.

Diagnostic search in patients of this age is based on endoscopic examination of the trachea and bronchi, scintigraphy and angiography of the lungs, tests for cystic fibrosis, determination of the concentration of aganititrypsin, etc. Finally, in all age groups it is necessary to exclude pulmonary tuberculosis.

In patients with severe immune deficiencies, when shortness of breath and focal infiltrative changes in the lungs appear, it is necessary to exclude:

• progression of the underlying disease;
• involvement of the lungs in the underlying pathological process (for example, in systemic diseases of connective tissue);
• consequences of the therapy (drug-induced lung injury, radiation pneumonitis).

Diagnosis of pneumonia

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Treatment of pneumonia in children

Treatment of pneumonia in children begins with determining the place where it will be carried out (in case of community-acquired pneumonia) and immediate prescription of antibacterial therapy to any patient with suspected pneumonia.

Indications for hospitalization for pneumonia in children are the severity of the disease, as well as the presence of risk factors for an unfavorable course of the disease (modifying risk factors). These include:

• the child's age is less than 2 months, regardless of the severity and prevalence of the process;
• the child is under 3 years old with lobar lung damage;
• damage to two or more lobes of the lungs (regardless of age);
• children with severe encephalopathy of any genesis;
• children in the first year of life with intrauterine infection;
• children with II-III degree hypotrophy of any genesis;
• children with congenital malformations, especially with congenital defects of the heart and large vessels;
• children suffering from chronic lung diseases (including bronchopulmonary dysplasia and bronchial asthma), cardiovascular system, kidneys, as well as oncohematological diseases;
• patients with immunodeficiency (long-term treatment with glucocorticoids, cytostatics);
• the impossibility of adequate care and compliance with all medical prescriptions at home (socially disadvantaged families, poor social and living conditions, religious views of parents, etc.);

The indication for hospitalization in the intensive care unit (ICU) or the intensive care unit (ICU), regardless of modifying risk factors, is suspicion of pneumonia in the presence of the following symptoms:

• respiratory rate of more than 80 per minute for children in the first year of life and more than 60 per minute for children over one year old;
• retraction of the jugular fossa during breathing;
• moaning breathing, disturbances in breathing rhythm (apnea, gasps);
• signs of acute cardiovascular failure;
• uncontrollable or progressive hypothermia;
• disturbances of consciousness, convulsions.

Indication for hospitalization in the surgical department or in the intensive care unit/ICU with the possibility of providing adequate surgical care is the development of pulmonary complications (synpneumonic pleurisy, metapneumonic pleurisy, pleural empyema, lung destruction, etc.).

Antibacterial treatment of pneumonia in a child

The main method of treating pneumonia in children is antibacterial therapy, which is prescribed empirically until the results of bacteriological testing are obtained. As is known, the results of bacteriological testing become known 2-3 days or more after the material is collected. In addition, in the vast majority of cases of mild disease, children are not hospitalized and bacteriological testing is not performed. This is why it is so important to know about the probable etiology of pneumonia in different age groups.

Indications for replacing the antibiotic/antibiotics are the absence of a clinical effect within 36-72 hours, as well as the development of side effects.

Criteria for lack of effect of antibacterial therapy:

• maintaining body temperature above 38 °C;
• deterioration of general condition;
• increasing changes in the lungs or in the pleural cavity;
• increasing shortness of breath and hypoxemia.

If the prognosis is unfavorable, treatment is carried out according to the de-escalation principle, i.e. they start with antibacterial drugs with the broadest possible spectrum of action, followed by a transition to drugs with a narrower spectrum.

The etiology of pneumonia in children in the first 6 months of life makes the drugs of choice even for mild pneumonia inhibitor-protected amoxicillin (amoxicillin + clavulanic acid) or second-generation cephalosporin (cefuroxime or cefazolin), and for severe pneumonia - third-generation cephalosporins (ceftriaxone, cefotaxime) in monotherapy or in combination with aminoglycosides, or in combination amoxiclav + clavulanic acid with aminoglycosides.

In a child under 6 months with normal or subfebrile temperature, especially in the presence of obstructive syndrome and indications of vaginal chlamydia in the mother, one can think about pneumonia caused by C. trachomatis. In these cases, it is advisable to immediately prescribe a macrolide antibiotic (azithromycin, roxithromycin or spiramycin) orally.

In premature infants, the possibility of pneumonia caused by P. carinii should be kept in mind. In this case, co-trimoxazole is prescribed along with antibiotics. If pneumocystis etiology is confirmed, monotherapy with co-trimoxazole is used for at least 3 weeks.

In pneumonia complicated by the presence of modifying factors or with a high risk of an unfavorable outcome, the drugs of choice are inhibitor-protected amoxicillin in combination with aminoglycosides or third- or fourth-generation cephalosporins (ceftriaxone, cefotaxime, cefepime) in monotherapy or in combination with aminoglycosides depending on the severity of the disease, carbapenems (imipenem + cilastatin from the first month of life, meropenem from the second month of life). In case of staphylococcal etiology, linezolid or vancomycin is prescribed separately or in combination with aminoglycosides depending on the severity of the disease.

Alternative drugs, especially in cases of destructive processes in the lungs, are linezolid, vancomycin, carbapenems.

Selection of antibacterial drugs in children of the first 6 months of life with pneumonia

Form of pneumonia	Drugs of choice	Alternative therapy
Mild typical pneumonia	Amoxicillin + clavulanic acid or second generation cephalosporins	Cephalosporins II and III generation in monotherapy
Severe typical pneumonia	Amoxicillin + clavulanic acid + aminoglycoside or cephalosporins of the III or IV generation in monotherapy or in combination with aminoglycosides. Linezolid or vancomycin in monotherapy or in combination with aminoglycosides	Carbapenems
Atypical pneumonia	Macrolide antibiotic	—
Atypical pneumonia in a premature baby	Co-trimoxazole

At the age from 6-7 months to 6-7 years, when choosing initial antibacterial therapy, three groups of patients are distinguished:

• patients with mild pneumonia who do not have modifying factors or who have modifying factors of a social nature;
• patients with severe pneumonia and patients with modifying factors that worsen the prognosis of the disease;
• patients with severe pneumonia and high risk of adverse outcome.

For patients of the first group, it is most appropriate to prescribe oral antibacterial drugs (amoxicillin, amoxicillin + clavulanic acid or second-generation cephalosporin cefuroxime). But in some cases (lack of confidence in following the instructions, a fairly serious condition of the child, when parents refuse hospitalization, etc.), a step-by-step method of treatment is justified: in the first 2-3 days, antibiotics are administered parenterally, and then, when the condition improves or stabilizes, the same drug is prescribed orally. For this, amoxicillin + clavulanic acid is used, but it must be administered intravenously, which is difficult at home. Therefore, cefuroxime is more often prescribed.

In addition to ß-lactams, treatment can be carried out with macrolides. However, given the etiological significance of Haemophilus influenzae (up to 7-10%) in children of this age group, the drug of choice for initial empirical therapy is only azithromycin, to which H. influenzae is sensitive. Other macrolides are an alternative in case of intolerance to ß-lactam antibiotics or their ineffectiveness, for example, in pneumonia caused by atypical pathogens M. pneumoniae and C. pneumoniae, which is quite rare at this age. In addition, if the drugs of choice are ineffective, third-generation cephalosporins are used.

Patients of the second group are shown parenteral administration of antibiotics or the use of a stepwise method. The drugs of choice, depending on the severity and prevalence of the process, the nature of the modifying factor, are amoxicillin + clavulanic acid, ceftreaxone, cefotaxime and cefuroxime. Alternative drugs if the initial therapy is ineffective are cephalosporins of the third or fourth generation, carbapenems. Macrolides are rarely used in this group, since the overwhelming majority of pneumonias caused by atypical pathogens are not severe.

Patients with a high risk of an unfavorable outcome or with severe purulent-destructive complications are prescribed antibacterial drugs according to the de-escalation principle, which involves the use of linezolid at the beginning of treatment, alone or in combination with an aminoglycoside, as well as a combination of a glycopeptide or fourth-generation cephalosporin with aminoglycosides. An alternative is the use of carbapenems.

Selection of antibacterial drugs for the treatment of pneumonia in children from 6-7 months to 6-7 years

Form of pneumonia	Drug of choice	Alternative therapy
Mild pneumonia	Amoxicillin. Amoxicillin + clavulanic acid. Cefuroxime. Azithromycin	Cephalosporins of the second generation. Macrolides
Severe pneumonia and pneumonia in the presence of modifying factors	Amoxicillin + clavulanic acid. Cefuroxime or ceftriaxone. Cefotaxime	Cephalosporins of the third or fourth generation, alone or in combination with an aminoglycoside. Carbapenems
Severe pneumonia with a high risk of poor outcome	Linezolid alone or in combination with an aminoglycoside. Vancomycin alone or in combination with an aminoglycoside. Cefepime alone or in combination with an aminoglycoside.	Carbapenems

When choosing antibacterial drugs for pneumonia in children over 6-7 years old and adolescents, two groups of patients are distinguished:

• with mild pneumonia;
• with severe pneumonia requiring hospitalization, or with pneumonia in a child or adolescent with modifying factors.

Antibiotics of choice for the first group are amoxicillin and amoxicillin + clavulanic acid or macrolides. Alternative drugs are cefuroxime or doxycycline, as well as macrolides if amoxicillin or amoxicillin + clavulanic acid were previously prescribed.

The antibiotics of choice for the second group are amoxicillin + clavulanic acid or second-generation cephalosporins. Alternative drugs are third- or fourth-generation cephalosporins. Macrolides should be preferred in cases of intolerance to ß-lactam antibiotics and in pneumonia presumably caused by M. pneumoniae and C. pneumoniae.

Selection of antibacterial drugs for the treatment of pneumonia in children and adolescents (7-18 years)

Form of pneumonia	Drug of choice	Alternative therapy
Mild pneumonia	Amoxicillin, amoxicillin 4-clavulanic acid. Macrolides	Macrolides. Cefuroxime. Doxacillin
Severe pneumonia, pneumonia in children and adolescents with modifying factors	Amoxicillin 4-clavulanic acid. Cephalosporins II generation	Cephalosporins III or IV generation

In patients with impaired immunity, empirical therapy for pneumonia begins with third- or fourth-generation cephalosporins, vancomycin, or linezolid in combination with aminoglycosides. Then, as the pathogen is identified, the therapy is either continued, for example, if pneumonia is caused by Enterobacteriaceae (K. pneumoniae, E. coli, etc.), S. aureus, or Streptococcus pneumoniae, or co-trimoxazole (20 mg/kg of trimethoprim) is prescribed if pneumocystosis is detected, or fluconazole is prescribed for candidiasis and amphotericin B for other mycoses. If pneumonia is caused by viral agents, antiviral drugs are prescribed.

The duration of the antibiotic course depends on their effectiveness, the severity of the process, the complication of pneumonia and the premorbid background. The usual duration is 2-3 days after a stable effect is achieved, i.e. about 6-10 days. Complicated and severe pneumonia usually require a course of antibiotic therapy of at least 2-3 weeks. In patients with impaired immunity, the course of antibacterial drugs is at least 3 weeks, but may be longer.

Choice of antibacterial drugs for pneumonia in patients with impaired immunity

Nature of immunodeficiency	Etiology of pneumonia	Drugs for therapy
Primary cellular immunodeficiency	Pneumocysta carinii. Fungi of the genus Candida	Co-trimoxazole 20 mg/kg as trimethoprim. Fluconazole 10-12 mg/kg or amphotericin B in increasing doses, starting with 150 U/kg and up to 500 or 1000 U/kg
Primary humoral immunodeficiency	Enterobacteria (K. pneumoniaeу E. coli, etc.). Staphylococci (S. aureus, S. epidermidis, etc.). Pneumococci	Cephalosporins of the 111th or IV generation in monotherapy or in combination with aminoglycosides. Linezolid or vancomycin in monotherapy or in combination with aminoglycosides. Amoxicillin + clavulanic acid in monotherapy or in combination with aminoglycosides.
Acquired immunodeficiency (HIV-infected, AIDS patients)	Pneumocystis. Cytomegaloviruses. Herpesviruses. Candida fungi.	Co-trimoxazole 20 mg/kg as trimethoprim. Ganciclovir. Acyclovir. Fluconazole 10-12 mg/kg or amphotericin B in increasing doses, starting with 150 U/kg and up to 500 or 1000 U/kg
Neutropenia	Gram-negative enterobacteria. Fungi of the genus Candida, Aspergillus, Fusarium	Cephalosporins of the third or fourth generation in monotherapy or in combination with aminoglycosides. Amphotericin B in increasing doses, starting from 150 U/kg and up to 500 or 1000 U/kg

Doses, routes and frequency of administration of antibacterial drugs for community-acquired pneumonia in children and adolescents

Preparation	Doses	Route of administration	Frequency of administration
Penicillin and its derivatives
[Amoxicillin	25-50 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 8 hours.	Inside	3 times a day
Amoxicillin + clavulanic acid	20-40 mg/kg body weight (for amoxicillin). For children over 12 years of age with mild pneumonia, 0.625 g every 8 hours or 1 g every 12 hours.	Inside	2-3 times a day
Amoxicillin + clavulanic acid	30 mg/kg body weight (for amoxicillin). For children over 12 years old, 1.2 g every 8 or 6 hours.	I/V	2-3 times a day
Cephalosporins I and II generation
Cefazolin	60 mg/kg body weight. For children over 12 years old, 1-2 g every 8 hours.	I/m, IV	3 times a day
Cefuroxime	50-100 mg/kg body weight. For children over 12 years old, 0.75-1.5 g every 8 hours.	I/m, IV	3 times a day
Cefuroxime	20-30 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 12 hours.	Inside	2 times a day
Cephalosporins of the third generation
Cefotaxime	50-100 mg/kg body weight. For children over 12 years old, 2 g every 8 hours.	I/m, IV	3 times a day
Ceftriaxone	50-75 mg/kg body weight. For children over 12 years old, 1-2 g once a day.	I/m, IV	1 time per day
IV generation cephalosporins
Cefepime	100-150 mg/kg body weight. For children over 12 years old, 1-2 g every 12 hours.	I/V	3 times a day

Carbapenems
Imipenem	30-60 mg/kg body weight. For children over 12 years old, 0.5 g every 6 hours.	I/m, IV	4 times a day
Meropenem	30-60 mg/kg body weight. For children over 12 years old, 1 g every 8 hours.	I/m, IV	3 times a day
Glycopeptides
Vancomycin	40 mg/kg body weight. For children over 12 years old, 1 g every 12 hours.	I/m, IV	3-4 times a day
Oxazolidinones
Linezolid	10 mg/kg body weight	I/m, IV	3 times a day
Aminoglycosides
Gentamicin	5 mg/kg body weight	I/m, IV	2 times a day
Amikacin	15-30 mg/kg body weight	I/m, IV	2 times a day
Netilmicin	5 mg/kg body weight	I/m, IV	2 times a day
Macrolides
Erythromycin	40-50 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 6 hours.	Inside	4 times a day
Spiramycin	15,000 IU/kg body weight. For children over 12 years old, 500,000 IU every 12 hours.	Inside	2 times a day
Roxithromycin	5-8 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 12 hours.	Inside	2 times a day
Azithromycin	10 mg/kg body weight on the first day, then 5 mg/kg body weight per day for 3-5 days. For children over 12 years old, 0.5 g once a day every day.	Inside	1 time per day

Tetracyclines
Doxycycline	5 mg/kg body weight. For children over 12 years old, 0.5-1 g every 8-12 hours.	Inside	2 times a day
Doxycycline	2.5 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 12 hours.	I/V	2 times a day
Antibacterial drugs of different groups
Co-trimoxazole	20 mg/kg body weight (as trimethoprim)	Inside	4 times a day
Amphotericin B	Start with 100,000-150,000 IU, gradually increasing by 50,000 IU per administration once every 3 days up to 500,000-1,000,000 IU.	I/V	1 time in 3-4 days
Fluconazole	6-12 mg/kg body weight	IV, orally	1 time per day

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Antiviral treatment for pneumonia in a child

Antiviral drugs are prescribed in the following cases:

• convincing laboratory or clinical evidence of viral etiology of pneumonia;
• severe viral-bacterial pneumonia.

In case of established or highly probable influenza etiology, children over one year old are prescribed rimantadine. In addition, starting from the first days of life, recombinant a-interferon - Viferon can be used. Indications for its use are rhino-, corona-, RS- and adenovirus infections, influenza and parainfluenza. Viferon is prescribed to children under 3 years old at 150,000 IU 2 times a day in suppositories for 5 days, to children over 3 years old at 500,000 IU 2 times a day in suppositories for 5 days. There should be 2-3 such courses with an interval of 5 days.

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Immunocorrective therapy

Recommendations for the administration of immunocorrective drugs in the treatment of pneumonia in children are still under study.

Indications for the appointment of immunocorrective therapy:

• age up to two months;
• the presence of modifying factors, with the exception of social and socio-domestic ones;
• high risk of adverse outcome of pneumonia;
• complicated pneumonia, especially destructive.

In these cases, along with antibiotics, replacement immunotherapy with fresh frozen plasma and immunoglobulins for intravenous administration is mandatory. Immunoglobulins are prescribed as early as possible - on the 1st or 2nd day. They are administered in normal therapeutic doses (500-800 mg/kg), at least 2-3 administrations per course, daily or every other day. In this case, it is desirable to achieve an increase in the patient's blood level of more than 800 mg/dL.

In destructive pneumonia, the administration of immunoglobulins containing IgM, i.e. pentaglobin-4, is indicated.

Symptomatic treatment of pneumonia in a child

Antitussive therapy is one of the main directions of symptomatic therapy. The drugs of choice are mucolytics, which thin bronchial secretions well by changing the structure of mucus (ambroxol, acetylcysteine, bromhexine, carbocysteine). They are used internally and by inhalation for 7-10 days.

Antipyretic therapy

Currently, the list of antipyretic drugs used in children is limited to paracetamol and ibuprofen. The indication for their use is febrile fever (over 38.5 °C). At a body temperature over 40 °C, a lytic mixture is used (0.5-1.0 ml of aminazine 2.5% solution + 0.5-1.0 ml of a pipolfen solution intramuscularly or intravenously). In severe cases, 0.2 ml per 10 kg of a 10% analgin solution is added to the mixture.

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Evaluation of the effectiveness of pneumonia treatment in children

The ineffectiveness of therapy and the high risk of an unfavorable prognosis for the disease should be discussed if the following is observed within the next 24-48 hours:

• increasing respiratory failure, decreasing the PaO2/P1O2 ratio;
• a drop in systolic pressure, which indicates the development of infectious shock;
• an increase in the size of pneumonic infiltration by more than 50% compared to the initial value;
• other manifestations of multiple organ failure.

In these cases, after 24-48 hours, a transition to alternative drugs and increased functional support of organs and systems is indicated.

Stabilization of the condition within the first 24-48 hours from the start of treatment and some regression of radiological changes and homeostatic disorders on the 3rd-5th day of therapy indicate the success of the chosen tactics.

The transition to taking antibacterial drugs orally is indicated:

• with persistent normalization of body temperature;
• when shortness of breath and cough are reduced;
• with a decrease in leukocytosis and neutrophilia in the blood.
• It is usually possible with severe pneumonia on the 5th-10th day of treatment.

Dynamic X-ray examination during the acute period of the disease is carried out only in the presence of progression of symptoms of lung damage or the appearance of signs of destruction and/or involvement of the pleura in the inflammatory process.

In case of clear positive dynamics of clinical manifestations confirmed by dynamic radiographs, there is no need for control radiography upon discharge. It is more advisable to conduct it on an outpatient basis no earlier than 4-5 weeks from the onset of the disease. Mandatory radiological control before discharging the patient from the hospital is justified only in cases of complicated pneumonia.

In the absence of positive dynamics of the process within 3-5 (maximum 7) days of therapy, a protracted course, torpidity to the therapy, it is necessary to expand the range of examination both in terms of identifying unusual pathogens (C. psittaci, P. aerugenoza, Leptospira, C. burneti), and in terms of identifying other lung diseases.

Read also: Treatment of pneumonia Treatment of hospital pneumonia

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Prevention of pneumonia in children

The basis for preventing community-acquired pneumonia is adequate treatment of upper respiratory tract infection, especially in frequently ill children and in children with broncho-obstructive syndrome. Special attention in the treatment of acute respiratory infections should also be paid to children suffering from encephalopathy, congenital malformations, children with grade II-III hypotrophy. In addition, children suffering from chronic lung diseases (bronchopulmonary dysplasia, bronchial asthma), cardiovascular diseases, kidney diseases (nephritis), oncohematological diseases and patients with immunodeficiency.

References

Tatochenko V.K., Sereda E.V., Fedorov A.M. et al. Antibacterial therapy of pneumonia in children: Manual for doctors. - M., 2001.

Rational Pharmacotherapy of Childhood Diseases: A Guide for Practicing Physicians: Book 1 / Edited by A.A. Baranov, N.N. Volodin, G.A. Samsygina. - M.: Litterra, 2007. - P. 451-168.

Respiratory tract infections in young children / Ed. G.A. Samsygina. - M.: Miklosh, 2006. - P. 187-250.

Technical basis for WHO recommendations for the management of pneumonia in children: Document WHO/ARI/91/20. - Geneva: WHO, 1991.

Buckingham SC Incidence and etiologies of complicated pneumonic effusion in children 1996-2001 // Pediatr. Infect. Dis. J. - 2003. - Vol. 22, N 6. - P. 499-504.

Juven T., Mertsola J., Waris M. et al. Etiology of community-acquired pneumonia in 254 hospitalized children // Pediatr. Infect. Dis. J. - 2000. - Vol. 19. - P. 293-296.

Henrickson KJ // Seminars in Pediatric Infection Diseases. - 1998. - Vol. 9, N 3 (July) - P. 217-233.

Guidelines for management of adult community - acquired lower respiratory tract infections. European Study on Community-acquired Pneumonia (ESOCAP) // Committee. Eur. Resp. J. - 1998. - Vol. 14. - P. 986-991.

Bush A., Carlsen R.-H., Zach MS Growing up with lung disease: the lung in transition to adult life // ERSM. - 2002. - P. 189-213.

Tatochenko V.K., Samsygina G.A., Sinopalnikov A.I., Uchaikin V.F. Pneumonia in children // Pediatric pharmacology. - 2006. - V. 3, No. 3. - P. 38-46.

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